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Direct Deposit Authorization Form

This document is an authorization agreement for direct deposit. It allows an individual to authorize a company to directly deposit funds into their bank account. The individual provides their name, social security number, bank account information, and signature. The agreement specifies that the company is not responsible for any errors in deposits. It remains in effect until canceled in writing.

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Deacon Wm Spencer Powell Sr.
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© All Rights Reserved
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17 views1 page

Direct Deposit Authorization Form

This document is an authorization agreement for direct deposit. It allows an individual to authorize a company to directly deposit funds into their bank account. The individual provides their name, social security number, bank account information, and signature. The agreement specifies that the company is not responsible for any errors in deposits. It remains in effect until canceled in writing.

Uploaded by

Deacon Wm Spencer Powell Sr.
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT

New Single Account Change


Important: This form will not be effective without a VOIDED check for the account number
indicated in Section 2 and this form is signed in Section 3 by the individual listed in Section 1

Name(Please Print) Agent Number SSN/Tax ID


1
I hereby authorize the above named company to deposit directly into my account listed below. If the company
erroneously deposits funds into my account, I authorize the company to initiate the necessary debt entries,
not to exceed the total of the original amount credited. Senior Life Insurance Company does not assume any
responsibility or liability for incorrect information entered on this form and may not be held responsible or
liable if an agent’s compensation is lost due to such error.

Depository Name Bank Credit Union City, State, Zip


Savings & Loan

2 Transit/ABA Number/Routing Number Checking Account Account Number


Savings Account

This authorization will remain in effect until canceled by the company or the company has received written
notification from me that is to be terminated in such time and manner for the company to act on it.
THERE WILL BE A 24 HOUR WAITING PERIOD BEFORE DIRECT DEPOSIT IS AVAILABLE
Signature Date
3
Please submit this completed form by fax to (229) 299-9987 or email to licensing@[Link]

DISCONTINUANCE OF AGREEMENT FOR DIRECT DEPOSIT

I hereby request the above named company to discontinue depositing my pay directly into my account
listed below, effective _______/_______/_________.

Depository Name Bank Credit Union City, State, Zip


Savings & Loan
Transit/ABA Number Bank Credit Union Account Number
Savings & Loan
Agent Name (Please Print) Agent Number

Address City State Zip Telephone

Signature Date

AAFDD2021

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